For over a quarter of a century the National Health Service has been exhausted by slow attrition. The political and technical managers of public health have uncritically adhered to the dominant neoliberal thought which considered the system unsustainable, inefficient, obsolete and have preferred to rely increasingly on the private sector rather than working to seriously qualify the public system. It’s time to say enough.
We called him assault (to universalism) – read here it’s here – but now it is clear that it was a siege; and maybe now it’s ainvasion. Readers will forgive the war language, but it gives a good idea.
For over a quarter of a century the National Health Service (NHS) has been under attack. It is not a sudden, violent and manifest action (characteristics of an assault), but one slow wear and tear aimed at conquering coveted territories, starving the population and forcing them to surrender (characteristics of a siege). A work aimed at isolating the besieged so that he cannot receive supplies from outside, avoiding unchivalrous devastation, keeping the rival in check, slowly weakening his resistance until he is forced to surrender himself to safeguard his own safety.
Rereading the story of the siege of Turin in 1706 this summer, I found myself thinking that the weakening of public health is the result of a work implemented with the strategies of the so-called scientific sieges who, in addition to the technique of taking by hunger and thirst, try to make breaches – carefully studied by military experts – to exhaust the besieged and induce him to surrender, ultimately perceived as a liberation from the risk of dying. The siege of Turin is one of the few cases that ended with the escape of the besiegers; historians give credit to the ability to implement an equally scientific defensive strategy, planning and implementing resistance and defense actions (fortification systems, underground tunnels, a huge water supply well, accumulation of ammunition, food supplies thanks to the involvement of farmers from neighboring territories, etc.). The city equipped itself over the years, aware that it could be the subject of bloody and dangerous sieges.
The NHS also suffered something similar to a long siege. And this has happened since Italy was also infected by the epidemic of reforms that involved health systems around the world, in the name of neoliberalism and the laws of the market (R. Klein). At the beginning there was, in 1992, the sudden and unscrupulous assault of the De Lorenzo law which, together with corporatisation, introduced – among other things – “differentiated forms of assistance” and “freelance intramural profession”. But the forces that wanted to contain the role of public health and open up to the privatization of the NHS took note of the opposition of the population and of Parliament (which approved two reforms to modify Legislative Decree 502/1992) and decided to adopt a strategy made of waiting and action: waiting for the progressive, autonomous attrition of the NHS and action to create breaches and invade the field.
Unfortunately, unlike the city of Turin, the NHS was unable to define a defensive line up to the challenge: the ’99 reform seemed sufficient, the breaches opened by the besiegers appeared temporary, the resistance staked everything on the dedication of professionals (imposing working conditions and salaries unacceptable in normal times), the population learned to tolerate increasingly delayed and tortuous access, the health planning was emptied of role and resources, etc.). A defensive line that played downwards and which could only lead to the progressive loss of some important public health functions, starting from that of public management in health policies. Except for a few dissonant voices that remained unheard, no one opposed the reduction of the NHS to the bare bones: in personnel, in hospital beds, in clinics, in mental health centres, in collective prevention, in the maintenance of technologies, in stocks of devices for emergencies, etc. The idea of having a bit of redundancy to deal with unforeseen events seemed completely out of place, ahistorical and wasteful.
All in a context in which the idea prevailed that reducing the role of the State and leaving it to the market was the best solution, and not only in healthcare. The besieging forces, bearers of the sector’s private interests, have always looked at the NHS as an obstacle to the development of the healthcare services market and the insurance coverage market, indifferent to the effects in terms of equity of the impoverishment of public healthcare.
At the same time, the political and technical managers of public health have uncritically adhered to the dominant neoliberal thought which considered the system unsustainable, inefficient, obsolete and have preferred to rely increasingly on the private sector rather than working to seriously qualify the public system. A very serious mistake.
And so, with the complicity of the media (which denounced medical malpractice while forgetting the many good health services), a single thought spread which combined the ambitions of the private sector and the disengagement of the public, and prepared the gaps for the growth of the for-profit market (through supplementary funds, the superticket, the lack of control of waiting times, etc.). Emblematic is the cap on spending on employee personnel in 2011, which has forced even the most attentive decision makers to outsource services or increase the use of accredited private individuals: as a rational entrepreneur, aware that his offer depends on the staff he has at his disposal, he would limit himself in the possibility of hiring qualified professionals, thus favoring competition ?
Then came the pandemic. The NHS operators (the besieged) found themselves without supplies (of beds, local services, devices, …) and tried to make up for it with their commitment. During the pandemic the NHS was fortified, but with emergency and non-structural measures. Today, the situation is particularly worrying not only because too many people struggle to access services, but above all because, one by one, all the topics that we thought had been swept away by the pandemic are returning: health is no longer a priority. Faced with the inevitable rigor that will be reintroduced anyway, halting the decline of the NHS seems almost impossible. And a small (or large) spending review seems to have already been written.
In reality, further doses of austerity in the healthcare sector should be declared unacceptable.
Is it conceivable to propose fighting in Europe to exclude from the debt calculation for a suitable number of years the investments necessary to restore an adequate supply of healthcare personnel and adequate remuneration of healthcare professionals in less structured countries? The training and inclusion of an adequate supply of human capital in the healthcare system is, in a labor-intensive sector, just as fundamental as the acquisition of technological equipment or the creation of healthcare facilities. Who can fight for this?
Nerina Dirindin, University of Turin.
International health systems assault, siege, Austerity, Covid-19, Europe, attrition, Neoliberalism, Pandemic, Health personnel, Health and market, Private healthcare, National Health Service (NHS), spending review